Puberty Blocker Consent Form

Identity Health Clinic

Puberty Blocker Consent Form
Every medication has risks, benefits, and side effects that are important to understand before starting. It is also important to know how they work.

Please initial each statement on this form to show that you understand the benefits, risks, and changes that may occur from taking these medications.

Medications for Blocking Puberty
I know that the Puberty Blockers are used to help temporarily suspend the physical changes of puberty.

Clear
I know it can take several months for the medication to be effective. I know that no one can predict how quickly or slowly an individual's body will respond.

Clear
I know that using this medication to block puberty in transgender youth is an off-label use. This means it is not approved by the Food and Drug Administration for this specific use. However it has been used for many years to block puberty in children who started puberty earlier than is healthy. I know that using a puberty blocker is based on the judgment and experience of our health care provider and is supported by the Society of Pediatric Endocrinology.

Clear
I know that the medication is not permanent. If treatment is stopped it will take about six months to restart puberty, beginning at the developmental stage the body was at when the puberty blocker was started.

Clear
I know that by taking these medications, the body will not make the hormones of puberty, testosterone, or estrogen. At this time, there is family support for "putting on hold" these hormones and the changes that they create during puberty.

Clear
I understand that use of this medication may help avoid the unhappiness and trauma of unwated puberty and pave the way for development in the affirmed gender, with a better fit between body and psyche.

Clear
I know that this medication may help avoid the need for surgeries and other treatments (e.g. mastectomies for trans men, tracheal shaving or electrolysis for trans women) that would be required to try to reverse the effects of puberty.

Clear
I know that, especially with transgender girls (assigned male at birth), use of this medication may improve safety and integration into society during adulthood. This is because transgender women who underwent male puberty are often unable to 'pass' as female because of irreversible changes that male puberty causes.

Clear
I know that transgender girls (assigned male at birth) can take spironalactone or bicalutamide instead puberty blockers to block the effects of testosterone.

Clear
I know that transgender boys (assigned female at birth) may have a menstrual period 2-4 weeks after first taking this medication.

Clear
I know that our family is encouraged to have ongoing consultation with a therapist experienced in gender issues while a puberty blocker is being prescribed.

Clear
All people with medical decision making rights and the patient have reviewed the above information.

Clear
Risks of Puberty Blockers
I know that the side effects and the safety of these medicines are not completely understood. There may be long-term risks that are not yet known.

Clear
I know that this medication may have an effect on final height. It is possible that transgender girls may reach a shorter height, more typical of women. In transgender boys, delaying the onset of puberty may actually result in slightly taller height. (One of the reasons that women are usually shorter than men is that puberty started at a younger age). Neither of these outcomes is certain.

Clear
I realize it is unknown whether there could be stalling of typical adolescent cognitive or brain development while on these medicines. If so, this will resume after discontinuation of medication.

Clear
I know that other people may notice that puberty has stalled, which may become increasingly apparent with increased age and ongoing pubertal development in peers.

Clear
I know that some transgender people experience harassment and discrimination. We are aware of resources for our family, and understand we may need to be advocates for safe participation, free from harassment, in schools and other activities. We know we can ask our health care team for help with this.

Clear
All people with medical decision making rights and the patient have reviewed the above information.

Clear
Prevention of Medical Complications
I know puberty blocking medication is to be taken only as prescribed. I agree to tell my health care provider if there are any problems or side effects with the medication.

Clear
I know that these medications can be stopped at any time, and that this should be done with the help of our health care provider.

Clear
I understand periodic check-ups are needed to monitor medical effectiveness and safety.

Clear
All people with medical decision making rights and the patient have reviewed the above information.

Clear
Patient Signature

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Patient legal name (health insurance name)
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Guardian Signature

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